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APPLICATION FOR WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 381,"6 N.SAN JOAaUIN ST,STOCXTON,CA/6201388 <br /> 1209)4813428 <br /> NOW-REFUNDABtE PERMIT EXPIRES 1 TEAR FROM GATE Mellen <br /> lEeaylots IS Tri,limetel <br /> Application Is here by aside to the San Joaquin County for a permit to construct and/or install the work destribed This application Is <br /> J mode in toapllam* with San Joaquin County Develaparant Title, Chapter 9 1115 3 and the standards of son Joaquin Canty Public Nealth , <br /> Bervfeea, Environmental Health Division ! <br /> Job Address/ofr/APN#14 WA-F r'/ L u u ( 4 City 5*b Parcel flee/APMR <br /> Owner's Name va D�•.r F+v� ►i Fav <br /> 4Address ,-., <br /> fN e K /)Phone/2 <br /> contractor C a li f uA A T i u J Address,4 X J PAeH [ =. <br /> tJ L bLIcM-a]�17- Phone 37Z �iuJ <br /> Sub Contractor Address <br /> L!e# Phone <br /> TYPE OF,WELL/PIMPr 11 NEW WELL 1) REPLACEMENT WELL 11 MONITORING WELt • <br /> LI OTHER / - <br /> [] DESTRUCTION [) OUT Qi-SERVICE WELL 11 GEOPHYSICAL WELL ! )(SOIL BORING 1­9 z GS( r <br /> U INSTALLATION 13 WELL SYSTEM REPAIR 11 CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WCLL <br /> (TYPE OF <br /> 11 NOagain N PJ <br /> Item R DEPTH PIMP SET FT FIRST WATER LEVEL <br /> Pl#iP) <br /> LNTENOED Us E TYPE OF 1FEL1 p0NITRUCIIDN BPECIFICATIONS <br /> y 11 INDUSTRIAL I) OPEN BOTTOM DIA OF WELL EXCAVATION DIA OF CONDUCTOR CASING <br /> — <br /> 0 DOMESTIC/PRIVATE 11 GRAVEL PACK/S(2E TYPE OF CASING/STEEL/PVC DIA OF WELL CASING <br /> LI PUBLIC/MUNICIPAL 11 DRIVER DEPTH OF GROUT SEAL T U i o f it�rfrKSPECIFIGTION <br /> I1 IRAIGATIONJAO a OTHER GROUT SEAL INSTALLED BY f. -+T -A eTl. GROUT BRAND NAME <br /> ANN ITORING GROUT SEAL PIMPED X Yes n No CONCRETE PEDESTAL BY DRILLER 11 Yes I1 No <br /> APPRDI( DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> AOPOBED CONBTIHi1.TlONIDRILLINQ YEfNOD MIA ROTARY_ AIA ROTARY_`AUGER CABLE`OTHER` <br /> I hereby certify that 1 hove prepared this application and that the work mitt 6e done fn accordance with San Jo in Count <br /> State Laws, and Rules and Regulations of the San Joaquin County Hone owner or licensed a ent's Signature aW f Ordinances, <br /> certify that in the perforainice of the work for which this permft is issued, I shall not D pnature certifies the fallowing I <br /> Laws of California • COntractor's hiring or sub contracts employ persons subject to that <br /> the <br /> COMPENSATION <br /> of the work for which this permit is Issued, I shall ^� signature certifies the following + I certify that Ln the performance <br /> employ persons subject to HORKNAN'S CONDENSATION Laws of California " TNEAPPIICANT <br /> MUST CALL 24 HOURS ADVANCE Fl"J,!l a ulgja INSPECTION$AT 12011401423 CoWtete drawing at lower ares provided <br /> Signed x � o� <br /> Title ASI r'rr M "nC, DateB <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 1 Names of streets or roads nearest to or bounding the property A Location of house sewage disposal <br /> 2 Outline of the property, giving dimensions and North direction B posel syssys or <br /> em <br /> 3 Dimensioned outlines and location of all exists proposed expansion of sewage radius <br /> of as systems <br /> structures inctudf io , driveways. <br /> 5 location of wells Within radius of 150 }t an <br /> and walks ^g covered areas such as patios, drirerays, the property or adjoining property <br /> fl <br /> I'll'/ <br /> T <br /> -J r 7 l A ! U A <br /> DEPARTMENT USE ON;T <br /> Application Accepted By C.� <br /> Date <br /> _�(� <br /> Grout Inspection$y Date <br /> Pimp Inspection By Date <br /> Destruction Inspection By Date <br /> Comments <br /> ACCOUNTMO ONLY AID# FAC# <br /> PE CODES FEE INFO AMOUNT NEMITTED CNEC"CASH RECEIVED IY pATE 110111TI$EAVLCE REQUEST NUMBER INVOICE <br />